Healthcare Provider Details

I. General information

NPI: 1821113119
Provider Name (Legal Business Name): CHARLES TIFFANY BARRET P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 SE KLAH CHE MIN DR
SHELTON WA
98584-9216
US

IV. Provider business mailing address

3040 LILLY RD NE
OLYMPIA WA
98506-3007
US

V. Phone/Fax

Practice location:
  • Phone: 360-427-9006
  • Fax: 360-427-1951
Mailing address:
  • Phone: 360-491-7917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10000621
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: